The Utility of Intraoperative Cystoscopy in Major Vaginal and Urogynecologic Procedures
Drs. C. Kwon, R. Goldberg, S. Kodur, L. Atkuru, P. Sand
Evanston Continence Center

Objective:  Examine the frequency of significant cystoscopic findings during major vaginal and anti-incontinence surgeries. 
Methods:   The records of 526 women who underwent routine transurethral cystoscopy with intravenous injection of indigo carmine at the time of their urogynecologic and major vaginal procedures between January 1, 1997 and April 20, 2001 were reviewed.  We determined the incidence of significant cystoscopic findings and their effects on intraoperative management.  Two-tailed t-tests and logistic regression analysis were used to compare characteristics between the groups with and without significant cystoscopic findings. 
Results:    Of the 526 patient records, 79 subjects (15.0%) had no anti-incontinence operation performed.  Thirty-two of 526 patients (6.0%) had significant findings on cystoscopy.  Three of these had been diagnosed preoperatively.  Three intraoperative cystotomies occurred during abdominal Burch procedures that were detected before cystoscopy.  Twenty-six significant findings (4.9%) were unsuspected before cystoscopy.  Of these, fifteen (2.9%) were operative injuries that required intervention.  There were no unrecognized injuries causing morbidity postoperatively.  There were no significant differences between patients with abnormal and normal cystoscopic findings in regard to mean age, weight, smoking, parity, estimated blood loss, previous surgery, or previous incontinence surgeries.  Of 79 patients with no anti-incontinence procedure performed, there was 1 partial ureteral obstruction from an anterior colporrhaphy (1.3%).  Seven of 184 Burch procedures (3.8%) resulted in injuries to the lower urinary tract. Three injuries (1.6%) required intervention and were unrecognized prior to cystoscopy.  This rate of injury (3.8%) for Burch procedures is lower than the 9% rate recently reported.  Seven of the 20 cases requiring intervention were caused by anterior colporrhaphy (7/346).  No complications or morbidity occurred as a direct result of intraoperative cystoscopy. 
Conclusion: Intraoperative cystoscopy with intravenous indigo carmine is a safe and effective way to detect injury of the lower urinary tract.  With a significant rate of detection, cystoscopy allows for immediate recognition and easier repair of lower urinary tract injury, lowering patients’ risk for morbidity.  Anterior colporrhaphy was associated with the greatest risk (2%) of unrecognized ureteral compromise. 
Key Words:   Cystoscopy, Urinary Tract Injury, Urogynecologic Surgery